Failure to Timely Report and Investigate Alleged Abuse
Penalty
Summary
The facility failed to ensure that allegations of physical abuse involving two residents were reported immediately and that the required five-day follow-up investigation report was submitted to the State Agency in a timely manner. One resident, who had dementia and severely impaired cognition, and another resident, who had a history of subarachnoid hemorrhage and moderately impaired cognition, were both identified as vulnerable adults in their care plans. The care plans specified that any situation identified as abuse or potential abuse would be reported per facility protocol. On the evening in question, a CNA heard a thud and a resident shouting from behind a closed door while another CNA was providing care, and also overheard a second resident telling the same CNA to stop being rough. The CNA did not report these concerns until her next shift, two days later, stating that there was no one available to report to at the end of her shift and that she was unsure if what she witnessed constituted potential abuse. The delay in reporting meant that the alleged perpetrator continued to work additional shifts before being suspended pending investigation. The facility's initial report to the State Agency was made after the delayed internal report, and the follow-up investigation report was not submitted within the required five-day period. The DON later discovered that the report had not been submitted due to a possible system error or user mistake. The facility's policy required immediate reporting of all alleged violations and completion of the internal investigation within five working days, which was not followed in this instance.